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Sitting in the Chair's Chair with Stuart Bertsch · Style Points

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Hello anesthesia enthusiasts, and welcome to the 12th episode of Style Points.
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For those of you who have been keeping track, Style Points has been released once a month
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for 12 months, meaning that this marks the full year of Style Points episodes.
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Before we start with today's interview with interim chair of our department, Dr. Stu
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George, I'm going to hand it over to my co-host, Nate Moore, to introduce our resident guest
0:31
for today's RSI.
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Thanks, John.
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I have the honor of introducing Dr. John Galvin, who is one of our interns here at
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the University of Cincinnati.
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We have pulled him from his critical care rotation to talk to us about PONV prophylaxis.
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John, set the scene for us.
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It's Friday afternoon, and you've just finished your last case of the day.
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You're on your way out of the PACU after handing the patient off when you suddenly get a phone
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call.
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Your otherwise healthy patient, who just had a laparoscopic cholecystectomy, is vomiting
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uncontrollably, and the nurse says they've already given the PRN-zofran you added to
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the patient's PACU orders.
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What now?
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About one-third of patients who receive inhalational anesthesia will develop post-op nausea and
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vomiting, or PONV, if they don't receive prophylactic intervention.
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PONV is not just unpleasant for patients.
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It can also lead to delayed discharge from the PACU, aspiration, wound dehiscence, and
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may even require unanticipated hospital admission.
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So, how does an outstanding anesthesia resident like you prevent a situation like the vignette
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I just described?
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First, we'll talk about how to make an anesthetic plan that accounts for PONV risk factors.
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Then, we'll cover some anti-emetic medications that you can use for prophylaxis.
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In 1999, Dr. Christian Apfel and his co-authors published a paper on PONV risk stratification
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and what is now commonly known as the Apfel score.
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The four risk factors were female gender, history of PONV or motion sickness, non-smoking,
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and the use of post-operative opioids.
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Patients with no risk factors had about a 10% risk of PONV, and patients with one risk
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factor had about a 20% risk of PONV.
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Each additional risk factor added about 20% each, so that a patient who is an otherwise
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healthy female who does not smoke but does get motion sickness every time she gets in
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the car now has about a 60% chance of PONV.
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If her perioperative pain regimen also includes opioids, her risk jumps up to 80%.
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So to recap, an Apfel score of 0 corresponds to a 10% risk of PONV, and Apfel scores of
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1, 2, 3, and 4 correspond to PONV risks of 20, 40, 60, and 80%.
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Now let's talk about what we can use to lower the risk of PONV.
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The fourth consensus guidelines for the management of PONV recommends giving two anti-emetic
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agents to all patients with one or two risk factors, and giving three to four anti-emetic
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agents to all patients with more than two risk factors.
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A number of receptors contribute to nausea and vomiting, including receptors for serotonin,
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dopamine, histamine, neurokinin 1, GABA, and muscarinic acetylcholine receptors.
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Ondansetron, or a Zofran, is a serotonin antagonist and is commonly given at 4 mg IV around 30
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minutes before the end of surgery.
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Serotonin, or 5-HT3 receptors, can be found in the GI tract as well as the chemoreceptor
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trigger zone, also known as the CTZ, which is in the medulla.
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Scopolamine is an anticholinergic medication often used as a transdermal patch and also
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acts on the CTZ.
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Because of its slower transdermal release, scope patches are most effective when applied
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to the patient before surgery rather than during or after.
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Histamine receptors are found in the vestibular system, which is the inner ear, as well as
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the CTZ, so they're most commonly associated with nausea related to motion sickness.
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In addition to benadryl or diphenhydramine, meclazine, promethazine, and hydroxazine are
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antihistamines that might be more helpful when a patient's having more vestibular related
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nausea in the PACU.
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Dopamine plays a significant role in the vomiting response, so medications like haloperidol
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or droperidol can be useful as a rescue agent in the PACU as well, but are not typically
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first line when it comes to preventing PONB.
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NK1 receptors are in the brain and GI tract, and they respond to a neuropeptide called
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substance P, which is a key player in emesis.
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Aprepitent and phosphoprepitent are NK1 receptor antagonists and block the effects of substance
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P. While literature shows that NK1 antagonists have a significant duration of action, use
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is still somewhat limited to patients with cancer and the critically ill, and so it may
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also be related to higher cost.
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Corticosteroids like dexamethasone or decadron are commonly given upon induction of anesthesia.
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Be sure to give these after the patient is off to sleep though.
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If given awake, patients can experience a particularly uncomfortable perineal burning
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sensation.
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And while the mechanism isn't completely understood, they are thought to reduce nausea
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and vomiting by modulating neurotransmitter release and reducing inflammation.
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Benzodiazepines like Ativan can have a strong anti-emetic effect as well, especially when
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anxiety contributes to a patient's nausea.
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Last, but certainly not least, is propofol.
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Propofol is often used in TIVA protocols, and no, this isn't where the anesthesiologist
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wears sandals during the case.
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TIVA stands for total intravenous anesthesia and is often used to specifically minimize
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PONV due to the significant anti-emetic effects of propofol.
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It is thought to inhibit dopamine receptors, modulate serotonin release, and enhance the
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action of GABA, which might indirectly suppress the pathways responsible for nausea and vomiting.
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As you develop your patient's anesthetic plan to reduce their risk of PONV, remember
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that higher risk patients will benefit from anti-emetic medications more than lower risk
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patients.
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And because each anti-emetic reduces PONV by a fraction of the existing risk, each additional
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medication results in less benefit.
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The fourth consensus guidelines also recommends against re-dosing any medication of the same
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class within 6 hours after the initial dose.
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So consider choosing a drug from another class for PONV treatment in the PACU.
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I don't have time to discuss some of the medication risks, but remember that not all anesthesia
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needs to be done with a volatile anesthetic.
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Opioid sparing pain regimens and multimodal pain control will also reduce your patient's
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risk of PONV.
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VIVA can reduce the risk of PONV by as much as 20%, and regional anesthesia should be
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considered for patients who might not be good candidates for general anesthesia.
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With these guidelines in mind, you won't just be the star of the OR, you'll be the MVP of
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PACU and a PONV VIP.
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Thanks John, I think I'm feeling better already.
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Now on to today's guest.
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Dr. Stu Birch is the Interim Chair of the Department of Anesthesiology here at the University
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of Cincinnati.
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He's brought a lot of operational expertise to the position and has been a steadying presence
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for our department.
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Like myself, he's a big fan of FC Cincinnati, which is the MLS soccer team here in Cincinnati.
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Stu, we lost to NYC FC after missing three straight penalty kicks.
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I understand that you frequently go out for drinks with FC Cincinnati coach Pat Noonan.
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What do you plan to tell him that he needs to change for next season?
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Yeah, heartbreak and loss is really what I'd say.
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I mean, like you said, three straight PKs, looking at it.
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NYFC was a good opponent.
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I mean, obviously, couldn't come through.
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I wouldn't say I go out frequently with Pat for drinks, but we met in a bar in Philadelphia
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before the union game.
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We were actually there for the national conference and I was with a friend from the department
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and we were just strolling through Philadelphia and we stopped by a bar to just have a drink
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and Chris Albright was there and Pat Noonan joined him later on that evening.
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Great experience.
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Two guys that were nice and easy to talk to, respectful with their time, to a gracious
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fan.
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So I really appreciate it.
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I think we struggled all season long with attacking presence.
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We're so dependent on Lucio.
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I mean, he's amazing.
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Don't get me wrong, but if he's not ticking, then the team's not scoring.
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So we got to find other ways to put the ball in the back of the bat.
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And that's the bottom line.
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When you look at it, that was our doubtful.
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You go back to the 2023 season, when they won the supporter shield, and even kind of
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the little bit before that, we were winning games 4-3, 3-2, 3-1.
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I mean, scoring left and right, which is common in MLS really when you look at it.
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I think when you look at the construct of the 2014, there was a big emphasis on defensive
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capability.
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And I think that was intentional on probably Albright's part to try and build a core spine
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that was going to have a solid defensive run for the MLS Cup.
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They certainly did for the most part, right?
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One of the few goals conceived, I think, throughout the league, how to study in back line, which
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is great.
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But there's some work to do as we look next year in terms of signing Miles Robinson, making
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sure that he sticks around, making sure Lutov sticks around, obviously.
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And then obviously there's rumors of them bringing Ford in from the Belgian league right
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now in the Golden Boot last year.
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So we'll see what happens.
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But we've got to figure out how to put the ball in the back of the bat.
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Well, as you can hear, Stu is obviously a true fan of our soccer team.
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I still want to start out and ask you the same question that I ask everybody at the
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beginning of these, which is my get to know you question.
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If you could invite anyone in the world over for dinner, including somebody from the past
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or even from fiction, who would you invite and why?
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Yeah, I mean, it's a tough question.
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I think there's so many people who'd be interested in meeting, discussing with, having
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dinner with, would be wonderful.
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I'm going to approach it a little bit different way.
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I'm going to give you two.
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One that is near and dear to me and another that's kind of that long shot that you really
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don't have any kind of personal connection with, if you will, that you'd want to get
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to know.
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I think first and foremost, my grandfather.
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Thinking back through it, we were a military family.
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We were always spread out across the United States, even to this day, my brothers and
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I. We didn't always have the closest connections within our immediate family, not in a bad
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way or anything along those lines, but when you're in a military family and you're spread
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out, that just happens.
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Looking back and looking back through the course of his life, you have a guy who was
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born in 1920 and basically through the roaring 20s, lived through the Great Depression, World
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War II at that point in time, obviously, when the Korean War, Vietnam War, and many other
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things.
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Getting his perspective on worldly life in general and how he saw things.
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When he was still alive, kind of took some of that for granted, I guess, and didn't spend
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as much time as probably should have or tried to get down to see him more than what I was
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able over the past years.
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That'd be certainly, I think, one person that just want to pick his brain about the state
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of where we are today, both as a nation and what he sees from a personal perspective.
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He was obviously in the Navy for a career, he was in the USS Cass and Pearl Harbor when
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it was bombed.
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He lived through a lot.
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After the Navy, he got into education.
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He was a teacher and then became principal up in Michigan of schools there.
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I think there'd be actually a lot of connections to what we do now with higher education and
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how do we approach it, how do we get the best out of people moving forward.
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That's one that's kind of the personal connection for me that I would really like to see.
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I think the other one right now, interestingly enough, would probably be Elon Musk, to be
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honest with you.
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Wow.
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I'm sure he's a popular guy.
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Yeah, I'm sure right now he's a very popular guy right now.
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Well, maybe not.
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I don't know.
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I'm not going to get into that by any means, but really from a visionary perspective.
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In terms of what he sees with Tesla, what's going on with SpaceX, with the Boring Company.
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I think he's looking at life in a different manner than many of us are and to really pick
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his brain about some of those pieces.
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I think that that would be fascinating.
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I think as a leader, your role is to create a vision and really bring that vision to life
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as much as possible.
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It's not to dictate all the little nuances of how do we get there and what's being done,
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but okay, he wants to have interplanetary life.
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Okay, that's crazy.
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Just kind of getting to know him a little bit from those standpoints I think would be
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very, very fascinating right now.
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I think you're right.
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That would definitely be interesting.
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How long have you been sitting in the chair's chair?
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I think at this point in time, it's been a little over seven months around that period
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of time.
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It was back on April Fool's Day, which was already right.
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I kind of laugh at that.
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Maybe it's still not real and maybe somebody's just going to come back and tell me, oh, this
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is a big joke and you can go back to living your life the normal way that you want.
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That'd be good.
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Understood.
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Yeah.
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Of all of the people in our department, why do you think that you were tapped as the interim
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chair and there might be some overlap here, why did you accept the position?
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Yeah, it's an interesting question.
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I think maybe I've sucker-ridden across my forehead in some aspects.
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There's always a little bit of that when you look at it and I say that jokingly.
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I think that ultimately at the end of the day, they were looking for somebody to bring
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stability to the department, bring a level kind of head, even keel person as much as
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possible.
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I probably presented that across the board.
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There was certainly carried some operational aspects from the OR side of things, from the
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procedural area and I've been getting involved with more of the college side and getting
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to know people.
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But really, I think that that was probably the biggest thing when you look at it.
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I think that people throughout the department mostly trust me across the board, believe
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the things that I say and that that carried a lot of weight, I think, when they were probably
15:47
looking at the decision.
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Why did I accept it?
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I think that really when you look at it, you're presented opportunities to help others.
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I think at the end of the day, really wanted to make sure that our department was going
16:06
to stay intact, was not going to have severe, severe disruption and felt like I could hopefully
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help to stabilize that aspect of it.
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That's something that's near and dear to my heart.
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I have a lot of friends within the department.
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I don't want to see anybody leave at any point in time.
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So that was probably one of the biggest reasons for accepting it at that point.
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The other is when you look at it, you're always presented with opportunities and it's the
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old adage of you can be either sitting at the table and having the discussions with
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people or you can be on the menu.
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And I think that really making sure that we hopefully had a seat at the table and had
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actual discussions about things, that was kind of my biggest impetus for taking the
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role and going through at that point in time.
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So one of the things that we've talked about is the operational side of medicine.
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I wonder if you could define what that means and maybe what drew you to that aspect of
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healthcare?
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You're on your path for graduating from residency and all of a sudden you're in the operational
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side of medicine.
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What does that entail?
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I think that there's a lot.
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I think that there's a lot of overlap actually between anesthesiology and a lot of the operations
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on the clinical side of medicine, really when you look at it.
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Overall, when you talk about operations across the health system, there's a few things.
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That's the clinical care that is delivered and how does that reach the patient.
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So that's the end goal.
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The tip of the spear, if you will, is the patient care that we're delivering every single
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day.
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But then there's logistics that go into that behind the scenes.
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So what's the structure?
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What's the setup?
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What's the finances?
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What's the equipment?
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What's the culture?
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What are the safety mechanisms that you have in place?
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What are the redundancies?
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So that's really when they talk about operations in medicine or the operational logistics,
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that's really a lot I think about what you're talking about.
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Over the course of my career, I've probably always been focused on some of those details.
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I think even back to residency, some of that is you see a problem, go fix the problem.
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You can either be a contributor to the solution or you can just be kind of a complainer who's
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not going to help the situation out.
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And I think that that's really important when you look at that.
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So that was always, that's always been my life.
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It doesn't matter going back to college, high school, everything.
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And so I think that you see a problem, then how do we fix it?
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How do we make it better for others?
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So the course of my career back in Louisville for residency, chief resident during that
19:01
period of time, right, tried to help kind of not stabilize, stabilize isn't the right
19:08
word, but align schedules for the residents and make sure that we were really accomplishing
19:16
what we needed, but also making sure that the residents had opportunities for their
19:21
own learning and development really at that point in time, just the same.
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So that translated into the military, the military piece being part of what was the
19:32
C-STARS program in Cincinnati.
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But basically what we did was we taught aeromodical evacuation for critically wounded soldiers.
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So we were part of critical care, your transport teams.
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So we were the original CCAP, if you will.
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And I was not the original.
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There were many people before me, don't get me wrong.
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But in that there's a lot of logistics that go out of those.
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So you see the flight medicine side of things where you've got the pilots, the logistics
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operations officers who are coordinating all of the flights in and around theater or across
20:08
the globe.
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And then how do we then play a role within that?
20:12
How do you plan, right, for your missions that you're going to have to plan on eight
20:16
hours, but then you're going to have a couple of hours for enough auction stores and you're
20:20
transporting that auction with you, right, because you're not in a hospital setting,
20:24
you're on the back of an aircraft.
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So there were certain logistical pieces that really played out through that, that endeavor,
20:30
just the same.
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So let's talk a little bit, if you're willing to, about your experience in the military.
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When did you join?
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What branch?
20:38
I want to hear about it.
20:40
Sure.
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So as you heard earlier, I mean, obviously, military family, I think service to the country
20:45
is always a good thing.
20:48
I don't know that we need to go to the South Korean model, you know, or the Israeli model
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where everybody has to provide service.
20:56
Sure.
20:57
I think that, you know, it still is a calling for a lot of people.
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So but obviously, one of my other passions is passionate about the United States of America,
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right, just in terms of being a patriot.
21:09
I think making sure that freedoms are kept throughout the world.
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So I joined back really before medical school, after college, and joined the health profession
21:21
scholarship program at that point in time.
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Really was, I wasn't married, didn't have kids, and I felt a need that I needed to provide
21:31
back.
21:32
And so what it allowed me was the opportunities in medical school.
21:37
We would go during summers in medical school, we'd go down to Texas, you know, and see a
21:43
lot of different areas of the Air Force down there and get exposed to aeromedical physiology
21:49
in some aspects and some other opportunities that we have.
21:53
And then so medical school really didn't have tons of, you know, touch points with the Air
21:58
Force.
21:59
Third, fourth year, really third year, you didn't do too much.
22:03
Fourth year, you had to complete a rotation or two at some of the military institutions
22:07
just to kind of introduce yourself.
22:09
So we did some weight rotations.
22:11
And so that was really medical school.
22:15
After the health profession scholarship, there's really two or really three types of opportunities
22:22
that you have in residency.
22:24
So hopefully you're matching in the residency that you want.
22:27
They have a list of available residence spots, and you're competing for those across, you
22:34
know, everybody graduating that year, essentially, plus then also flight surgeons and other people
22:39
who are still currently in the Air Force at that point.
22:42
So there's what are called deferments, which are basically you do them at civilian institutions.
22:50
There are sponsorships where you still do them at civilian institutions, but the Air
22:54
Force is paying for it.
22:55
You accumulate a little bit more years of service afterwards that you have to provide
22:59
back.
23:00
And then there's actually residencies through the military itself, through the Air Force
23:04
or through the Army at that point in time.
23:08
So I was lucky enough to receive one of the civilian deferments, which allowed me to couples
23:14
match with my wife.
23:16
So that was then so basically during residency, I didn't have a lot of contact with the Air
23:21
Force at that point.
23:22
And so afterwards, then started active duty.
23:25
Like I said, that was brought up here for the Sea Starters program, which is an excellent
23:29
program for the Air Force.
23:32
Essentially it's embedding active duty physicians within civilian institutions and trying to
23:37
keep their skills up to date more than anything else, which I think is wonderful.
23:42
It's probably one of the premier things that the Air Force is doing versus some of the
23:46
other military branches that you'll see.
23:50
So I think that the Army, the Navy, they're trying to figure out how do they keep some
23:54
of those skills present.
23:56
You can imagine that in a wartime setting when you're taking care of soldiers, even
24:02
though, yes, they're young and healthy, they are a lot sicker than what you see in a normal,
24:08
what we call a military treatment facility or an MTF.
24:11
You normally have healthy 20 to 30 year olds across the board, maybe they have sports injuries,
24:18
you know, minor things, but it's not like you were level one trauma center or, you know,
24:24
quaternary academic center at that.
24:26
So it's how do you maintain those skills long term.
24:30
So we got Cincinnati and essentially I was deployed about six months later.
24:36
So my wife was a real trooper at that point in time.
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She had a two year old and a six month old and she was starting a job as a pediatrician.
24:46
So she had her hands more than full.
24:50
So I was overseas for about six or seven months during that period of time.
24:56
In Afghanistan.
24:57
We would fly in and around Afghanistan on what was known as the milk run, where you'd
25:03
kind of go around to the different bases and then come back to Bagram.
25:06
And then also we'd fly occasionally from Bagram up to Rammstein, Germany back at that point
25:13
in time.
25:15
So what was your role on those flights in Afghanistan?
25:18
So we were, like I said, part of that critical carrier transport team.
25:22
So that team, we essentially had three teams down range that would rotate kind of on ad
25:29
hoc basis as needed.
25:31
But it's composed of a physician, an ICU capable nurse, and then a respiratory therapist.
25:37
And so that's your small component team.
25:40
The physicians could be anesthesiologists, trauma surgeons, emergency medicine physicians,
25:46
and pulmonary critical care physicians.
25:47
So that's what they really consider as critical care physicians for the Air Force at that
25:52
point in time.
25:53
And so we'd be picking up soldiers from either forward surgical facilities or even established
26:03
facilities in and around Afghanistan and then transporting them back to what was the main
26:08
hub of Bagram.
26:09
So it was a spoken hub model kind of where there was a lot of different smaller hospitals
26:14
in and around the main ones that you'd have.
26:16
And so flights vary at that point in time just for how long and where you were going.
26:24
Sometimes you were on a couple of legs of the flight before you'd pick up your patient.
26:28
But really it was the transport of those critically wounded soldiers.
26:31
So whether they had mechanical ventilation, they were just critically wounded, or they
26:38
had multiple organ failure at that point in time, it just all varied across the board.
26:44
So how does your military experience change the way that you approach leadership of the
26:51
department?
26:52
Yeah, I think it's a very interesting question.
26:58
Really when you look at it, the military is obviously very hierarchical, right?
27:06
And that there is always a chain of command, no matter where you're at.
27:10
And you got to go up that chain of command.
27:14
There's benefits to that.
27:16
That also creates red tape and bureaucracy at times that can be problematic really when
27:22
you're making decisions across the board.
27:25
So I think when I look at it, it's really trying to balance how much hierarchy do we
27:32
need within the department versus how many levels are put, right?
27:40
And so for me, I think within the department, there's the personnel who are doing the work.
27:46
Those are the most important people really when you look at that.
27:49
Then you're going to have your division directors, if you will, or service line directors, site
27:54
directors, whatever you want to say.
27:56
Then you have your vice chairs and you have the chair at about that point in time.
28:02
That's already four layers, right, in that piece.
28:05
But I think you have to have some hierarchy in there.
28:09
It can't just be a complete kind of a flat hierarchy across the board because then I
28:15
don't think that actually you will have true ownership.
28:18
You don't necessarily know who the point person is of really where you need to go.
28:23
And then it ultimately be maybe one or two people or a small group of people who are
28:28
making the decisions, which is not really what you want.
28:30
What you want to do is you want to try and empower the people who are doing the work
28:33
to make as many of those decisions as you can and support them in that role more than
28:38
anything else.
28:39
So I think that's some of the pieces that I really take from the military is trying
28:44
to look at that.
28:45
I think really it's the interactions on small teams and how do you interact with one another
28:52
on a regular basis, create those connections, maintain those connections, and also really
28:58
kind of work in that cohesive environment.
29:01
And so for me, I mean, that was a piece.
29:03
I mean, we were together for six, seven months with the same team overseas and we certainly
29:09
had our ups and our downs.
29:11
And you learn from those experiences and you figure out, okay, what works, what doesn't
29:16
work.
29:18
How do you approach that individual when there's a conflict?
29:22
How do you resolve that conflict as best as possible?
29:24
What happens when that conflict's not resolved?
29:27
And then how are you going to move forward still to achieve the greater mission and success
29:32
at that point in time?
29:33
So those are some of the learnings that I would say I took really from that, kind of
29:37
translate a little bit today.
29:40
Being a department chair sounds like a scary, sort of overwhelming situation to be put in,
29:48
especially being sort of thrown in as interim chair.
29:53
What I wonder from your perspective starting the job, what does a department chair actually
30:00
do?
30:01
Is it day to day like?
30:03
What kinds of decisions are you making?
30:06
What are you responsible for?
30:07
I want to hear more about what the job entails.
30:10
Yeah.
30:11
So I think really when you look at it, I mean, I can speak to ours specifically, but there's
30:17
a couple of different ways that departments can be set up, right?
30:20
I would say most academic anesthesiology departments are really set up to gear towards the tripartite
30:28
mission.
30:30
Medical service, education, research.
30:33
You're going to now have probably more departments that are out there, which are really going
30:37
to only be geared towards the clinical side of medicine as well as the education and the
30:42
research piece may not be a large component of their department, if you will.
30:49
But so that's really what we're challenged with by the deans of colleges of medicine
30:56
is to really support that tripartite mission as much as possible.
31:01
I think, like you said, when you look at it, you take that step back.
31:09
Being somewhat responsible for around 160 to 200 people, however you want to lump people
31:15
into our department is very daunting.
31:19
And I think it's also a very large responsibility, one that I take very seriously because really
31:27
you have the well-being of all those individuals' lives at the end of the day.
31:35
And you're trying to make sure that they feel supported, that they're able to carry out
31:41
the mission, but then also that they're going to have jobs long term, to be honest with
31:46
you, right?
31:47
And at the end of the day, we need to make sure that we're maintaining our workforce
31:54
in an appropriate manner.
31:55
And so that's probably one of the biggest responsibilities, I think, when you look at
31:59
it as to the department chair is how do we look at the overall picture of the department?
32:05
Where do we need to focus resources to help us move forward?
32:10
Is that in the clinical realm?
32:11
Is it in the education realm?
32:13
Is it in the research realm?
32:15
And then how do we get to that point over a period of time?
32:20
The thing that I'll tell you is that nothing moves quick.
32:24
As I'm a very fast-paced guy, I move at a very high clip all the time, and I want people
32:31
to move at that pace too, but I also understand that things don't always move the way that
32:36
we want them to.
32:37
And so you have to recognize that.
32:39
So I think when you're looking at the day-to-day pieces, it's managing people, right?
32:46
And how are they behaving?
32:52
What are they tasked with?
32:55
What are their responsibilities?
32:58
And are they pushing the department in a forward manner that is conducive to where we want
33:03
to go as a group?
33:05
We obviously have a mission from within ourselves, one that we hold back to the field of anesthesiology
33:12
or the American side of anesthesiologists.
33:14
We also have a responsibility back to the College of Medicine and supporting the overall
33:20
College of Medicine's mission and then UC Health's mission, right?
33:23
And that's the clinical side of things.
33:25
The college is obviously more responsible for the education and the research innovation.
33:29
And so that's kind of some of those areas that we're looking at is really what I would
33:38
say.
33:39
You're probably making one big decision a day, if that, on a regular basis.
33:45
The rest you're trying to help delegate the decisions or drive consensus amongst people
33:51
more than anything.
33:53
You want to gain the support of a majority of your faculty.
33:57
People will never be 100%.
34:00
Not everybody's going to be happy with decisions that are made.
34:03
But I think that being open, honest, as transparent as possible during that period of time so
34:08
they understand what thoughts were made or what thoughts went into the decisions that
34:14
were made would be some of those pieces.
34:17
So can you give an example of one of these big decisions that you've made recently and
34:23
sort of what your thought process was going into that?
34:28
Sure.
34:29
I think if you look at it, we were approached with an opportunity to pick up an additional
34:35
site, right?
34:36
What does that mean?
34:39
Yeah, so I mean, I don't want to get into too much of the specifics in terms of the
34:43
site itself.
34:44
But we were offered an opportunity to basically cover another area's hospital and pick up
34:56
care on obstetric floor with obstetric patients and also obstetric OR care.
35:04
So we hadn't really expanded outside of the walls of our institution for a long period
35:11
of time.
35:13
And so when you look at this, the question is, is this where we want to go?
35:18
Is this what we want to do?
35:20
Does this fit into our overall mission?
35:22
Right?
35:23
And try to balance that.
35:25
Because right now, if you look at it, I mean, a lot of departments are short staffed.
35:30
We don't have enough anesthesiologists.
35:32
We don't have enough Sierranes.
35:34
We're woefully undersized when you look at the residency program for where we should
35:38
be for the number of anesthetics that we're doing on a regular basis.
35:42
And you have to evaluate that decision.
35:45
Are the financials that you're gaining from it worth what you're going to be putting into
35:50
it?
35:51
Are the intangibles of building relationships, showing growth, encouraging new thought processes
36:02
amongst faculty, are those intangibles worth that as well?
36:06
Because you're going to be faced with challenges where you may not have enough people to potentially
36:12
staff that site, or you're going to stretch your own individuals a little bit further
36:17
than what they were allowed, or what they would feel comfortable with.
36:23
And you don't want to push them to that point then when they're looking to leave and to
36:26
go kind of outside and go to a separate group across the board.
36:32
So it's evaluating the financials, evaluating the intangibles, evaluating, you know, what
36:38
are you going to gain from this?
36:41
Is that going to be beneficial for the department long term?
36:44
Or is it really going to be, you know, a detriment to the department and really something that
36:50
we should say no to or we should say yes to?
36:53
So I don't know if that helps.
36:54
I mean, it's, it's, I'm trying to, you know, yeah, I mean, so that's a bigger example,
37:01
I think, that you really have to kind of evaluate.
37:04
As we look at the next fiscal year, how many sites are we going to increase across UC health?
37:10
We have two to four ORs that go unutilized from a physical space capacity right now.
37:16
Okay, how are we going to open those ORs up?
37:19
All right.
37:20
Offsite expansion.
37:21
How many offsite should we open up at Clifton campus versus the Westchester campus, right?
37:27
That's our northern campus and our southern campus really when you're looking at it.
37:30
And so those are the types of decisions that you're really trying to evaluate at that point.
37:36
And I think that that actually helps answer one of the previous questions too about what
37:41
is meant by logistics.
37:43
All those things that you mentioned seem like significant logistical challenges, but I'm
37:48
glad that somebody like you, who I always see in meetings and always reading books is
37:54
somebody who is handling those types of issues.
37:59
Speaking of reading those books, I frequently see you, I see a couple of books on your desk
38:04
right now.
38:05
I see you reading books about leadership, about management crisis resolution.
38:11
First of all, what are you hoping to gain from reading those books?
38:15
Why are you reading them?
38:17
And then what's maybe something that you've learned from reading these books?
38:21
Yeah, I think it's interesting when you look at successful people.
38:30
Some of the most successful people in the world and in history read about a book per
38:36
week.
38:37
I'm not there.
38:42
I feel like I have two tasks right now with department concerns as well as family concerns
38:47
where I don't necessarily read as much as what I should read more than anything else.
38:53
The thing that I would tell you is to be honest, leadership is a skill you can learn.
39:00
You're not born with it.
39:03
It's not inherent.
39:06
It's something that you have to work on.
39:08
And so what I'm trying to gain is knowledge, information, nuances of how to approach situations
39:17
and how to improve myself so that I can be the best version of myself.
39:23
But really what I consider it is really like kind of a head coach of a team or kind of
39:29
just a coach in general.
39:30
But then how do I get the best out of others?
39:33
Because that's really what I want is I want to make sure that we're getting the best out
39:36
of each individual throughout the department every single day.
39:39
And if we can get people from being good to better and better to great, then we're accomplishing
39:46
what we want long term.
39:49
So those are the things that I'm looking for when I'm reading some of these books, whether
39:54
it's leadership skill, communication skill, and operations management structure, right?
39:59
All of those different things.
40:02
There's always something to be learned from a book, from an individual, from a discussion.
40:08
You're always gaining information and just trying to get a little bit better every single
40:11
day.
40:13
I think a lot of the things that you probably gain from reading these books is more intangible
40:19
and sort of subtly shifts your thought process to act in one way versus another.
40:25
But can you think of any example of something that you've approached differently because
40:30
of something that you've read?
40:33
I'm sure there's many examples.
40:35
I'm trying to figure out kind of a little bit of a specific.
40:38
One of the books that I thought actually was really good that I read recently was What
40:42
Got You Here Won't Get You There.
40:44
And really talking about, I think it's Michael Goldsmith, but really talking about how do
40:52
you approach yourself to look at the influence that you have with people and the persuasion,
41:06
if you will, because you could be the best anesthesiologist in the world, right?
41:10
You could be the smartest person in the world.
41:12
You can provide the greatest patient care every single day, but that doesn't mean that
41:19
you're going to be a great leader, manager, visionary, or anything like that.
41:25
And so it's how do you develop the skills necessary to push yourself outside of your
41:33
comfort zone and challenge yourself to gain better insight to the communication issues,
41:41
right?
41:42
How do you communicate with people?
41:43
How do you communicate with the department?
41:46
How do you communicate outside?
41:48
How do you approach things with situational awareness and understanding emotional intelligence
41:52
and making sure that you're always going to have kind of a measured response at that point?
41:57
So that's really what the gist of the book is, is the things that got you to be successful
42:01
don't necessarily mean that you're going to be successful in your next role, right?
42:06
And you have to develop those skills, attributes, characteristics each and every day.
42:11
And so I thought that that was an excellent book and really it solidifies a lot of like
42:17
a kind of coaching principles more than anything else across the board.
42:21
So all these things that you've mentioned seem like they fit into the idea of creating
42:27
a departmental culture that we're looking for.
42:30
That's something that we can be proud of.
42:33
I think that culture personally is one of the most important aspects of the workplace.
42:38
So in your experience, how can we foster a positive productive culture within our department?
42:44
Yeah, I mean, I think as Peter Drucker says, you know, culture is strategy for breakfast
42:50
every single day.
42:51
It matters the most, right?
42:52
It is probably the number one thing that a leader can do within their sphere of influence,
43:01
if you will.
43:02
And that's an internal sphere of influence.
43:03
It's an external sphere of influence really when you're looking at that.
43:07
And so, you know, I think it's how do you make it an environment where people want to
43:14
come every day to work?
43:18
You know, culture is really defined by how your employees feel on Sunday night.
43:25
They want to come to work the next morning on Monday morning, they want to be there,
43:30
or they dreading it and they'd rather just wait for the next weekend and, you know, make
43:34
sure that they're having all the vacation time in the world or that's what they really
43:37
want, right?
43:38
I think that that speaks wonders too.
43:41
And so, but it's again, it's creating connections with people and it's within the department
43:50
having those connections permeate throughout.
43:55
It's teamwork, it's collaboration, it's a respectful mind frame, you know, a respectful
44:02
manner of how they interact every single day and really trying to make it a joyful experience
44:09
as much as you can.
44:11
That being said, at the end of the day, it's still work, it still is a job, it still is
44:16
a career, there's going to be days that are hard.
44:19
But if you can support your individuals, you can make sure that they are valued and that
44:25
they understand that, yeah, today might not have been perfect, but you know what, we're
44:29
going to work on fixing that down the road.
44:31
I think that's really where you talk about building that cultural long term.
44:36
And so, for me, it's about the connections with people, it's about relationships and
44:41
then how the people within the department behave together as a whole.
44:45
Do they look out for one another or are they just really in it for themselves?
44:50
Well, speaking of culture, I see in front of me there are some different extremely interesting
44:57
looking foods.
44:58
Do you still have some of those wasabi flavored Kit Kats around?
45:02
I think all of those got eaten up, unfortunately.
45:05
We've got some matcha Kit Kats that are left over, but it was great.
45:09
We went to Japan over the summer and really Kit Kats are a big thing over in Japan.
45:15
So they have all these different flavors.
45:17
It's a great little kind of a treat.
45:20
It's not as sweet as our normal chocolate is.
45:23
It's very savory.
45:24
I mean, the Japanese, it's not a very heat forward culture.
45:30
It's more of umami, if you will, flavorful across the board.
45:35
And so that's really what the Kit Kats were as well.
45:37
So I had brought a bunch of, you know, my wife takes care of the conference room table
45:44
and make sure there's snacks all the time for people, that there's sweets, there's
45:49
savory stuff.
45:50
But we had brought some of those Kit Kats from Japan and taken our two week vacation
45:55
over there.
45:56
But I think most of them, yes, have unfortunately been consumed.
46:01
So you've talked a little bit to me before about the Japanese culture and what you find
46:07
interesting or fascinating about that, especially compared to our own.
46:10
And I wonder if you could speak to that.
46:12
Yeah, I think it's very fascinating.
46:16
I mean, obviously, Japan has been a nation far longer than America has.
46:22
And they've developed a very cohesive culture over those number of years.
46:30
And so it's a big contrast to America, really, when you look at it.
46:36
But there's kind of two things that I really take away from Japanese culture.
46:41
One is the concept of Ikigai, which is meaning kind of, you know, your personal worth, your
46:48
profession, your purpose, right, for living, for meaning, which I think is great.
46:55
And it's not about, you know, being wealthy.
46:58
It's not about going and making money.
47:01
It's about how do you view yourself, your values, along with your profession, along
47:10
with your hobbies, right, to be a very, you know, holistic kind of individual, if you
47:17
will.
47:18
So I think that that's a great concept, really, when you look at it.
47:22
Because as we were talking about culture, there's going to be bad days.
47:26
So you got to figure, OK, what do I really like about, you know, what I'm doing right
47:32
now?
47:33
What do I dislike about that?
47:34
OK, how do I how am I going to make that better long term?
47:35
How does that align with what I want to accomplish in life, both for me, my family, my spouse,
47:42
right, my kids, all of those kind of pieces.
47:45
And so that concept, I think, is one that resonates with me.
47:48
The other one is really the concept of Kaizen, which is continuous improvement and really
47:55
seeking perfection.
47:56
And so when you go to Japan, everything is geared towards that.
48:02
It doesn't matter what your profession is.
48:05
It's how do we make things perfect all the time?
48:09
And so some of the examples of that, which I found was just amazing, was some of the
48:14
restaurants.
48:15
And, you know, you go to some of the restaurants here within America and you've got menus
48:21
that are about five pages long and now think about potential waste of all of that food,
48:30
whether it's in the freezer or people want it and they don't eat it.
48:37
There's a lot that could be kind of generated from that.
48:41
The restaurants over there, it's all specialized.
48:44
So if you're going to a sushi place, guess what?
48:46
They serve sushi.
48:47
If you're going to a ramen place, they serve ramen, right?
48:49
If you're going to a barbecue place, that's all they have.
48:52
And so they're trying to always create this perfection, right?
48:57
So the ramen shops are all geared at how do we make the very best ramen every single day?
49:04
And it's just the flavor is amazing.
49:07
The minimal waste is amazing when you look at it.
49:10
And I think it just that that concept of Kaizen of how we always get better, how do we strive
49:16
for perfection each and every day, no matter what we do, is evident all throughout the
49:21
culture.
49:22
And so I think it's great when you look at that and there's some good learnings that
49:26
I think that we can take away from it.
49:28
Absolutely.
49:29
That's really interesting to hear about.
49:31
I appreciate you, Sharon.
49:32
One of the things that I wanted to ask you about is on behalf of some of the medical
49:37
students or early residents that might be listening to us, what advice would you give
49:42
somebody who wants to be in your sort of role someday, somebody who wants to maybe be a
49:51
significant leadership position?
49:54
What would you tell a medical student who is interested in becoming chair of their department?
49:58
Or maybe what would you have told yourself?
50:04
I think really it's looking at oneself.
50:09
And when I talk with the medical students a lot these days, or even in the past, and
50:15
even the residents, to be honest with you, it's figuring out what's your purpose in life,
50:22
right?
50:23
What is it that you want to do and to accomplish that's going to fulfill you long term?
50:33
That's really what truly matters.
50:36
And so I didn't ever strive to want to be a chair of a department.
50:41
I didn't strive to ever want to be a medical director of anything, right?
50:45
I don't have aspirations to be a COO or a CEO.
50:49
That's not what I want.
50:51
That's not what I get purpose out of.
50:54
What I get purpose out of is am I helping somebody every single day?
51:01
Is what I'm doing today going to help somebody?
51:04
So that could be a patient.
51:07
It could be a faculty member.
51:08
It could be an employee with the department.
51:11
It could be a medical student.
51:12
It could be a resident.
51:13
But that's my purpose.
51:15
And this really allows me to help, I think, fulfill that long term.
51:20
And so that's really what I would try and solidify for people is to try and figure out
51:26
what makes you get up in the morning.
51:28
What makes you tick?
51:30
What do you view as that purpose in life for yourself?
51:34
Because that's then going to guide you, not how do I strategically plan for this position
51:42
or to get to that point in time.
51:44
Because I think that that's really looking at the wrong areas of how to do it.
51:48
And you're going to lose sight of the why you got into it.
51:52
Why were you an anesthesiologist?
51:54
Why did you want to go be a doctor?
51:58
People don't go to be a doctor to make money.
52:01
If they do, they're going to get burnt out long term.
52:03
They go to be a doctor because they truly want to help others.
52:07
They want to help patients.
52:09
They want to make sure that we're being healthy.
52:13
And I think that those are all kind of the keys that I would say.
52:15
And so that's the biggest thing for people to rectify with themselves.
52:20
And I think once they do that, they start to gain inner peace and understanding of where
52:27
they might go with their career and how they might approach the next steps of their lives.
52:34
Well there's a lot of overlap with what you said and what I'm about to ask you.
52:38
But we'll see if we can find some middle ground here.
52:42
One of the last questions I always ask is about your style points.
52:46
So what style points or points of personal preference have brought you success in your
52:50
career both in and out of the operating?
52:55
I think really when you look at it, it's being efficient.
53:02
Resources are very precious these days, whether that's equipment, drugs.
53:08
We see that every single day with IV fluids right now.
53:13
But time, people don't always look at time and being efficient with time across the board.
53:19
And so for me, the style points in and out of the operating room are trying to be as
53:24
efficient as possible.
53:26
So not cut corners.
53:30
Don't hear me when I say cut corners.
53:32
You do things in the appropriate manner, making sure that it's all safe and done the proper
53:38
way but making it more efficient.
53:41
Can we save time?
53:42
I always joke with the residents, but have you ever extubated under the drapes as the
53:49
last stitch is going into the abdomen?
53:52
That's what I'm talking about, right?
53:54
That's being efficient, right?
53:56
It's not being unsafe at that point in time.
54:00
So those are some of the things that I've really kind of impressed about people.
54:03
But there's ways of being efficient in and out of the operating room, I think, when you're
54:08
looking at that across the board.
54:10
Well one thing that I've told people before is that efficiency is one of my core values.
54:14
So I definitely agree with you on that.
54:17
And Stu, thank you so much for joining us.
54:20
I really appreciate your words of wisdom and I really enjoyed talking to you today.
54:25
Thank you.
54:26
I appreciate it.
54:27
Well, that's it for this month's episode.
54:29
If you've enjoyed the first year of Style Points, you can give us a Christmas present
54:34
by giving us a good rating in your podcast app, subscribing to the podcast, or telling
54:38
your friends about it.
54:39
As the first year comes to a close, I also want to give a shout out to our biggest fan,
54:45
Travis from the Pacu, who is always giving me great feedback about the podcast.
54:49
Travis, I appreciate you.
54:51
Take a deep breath, open your eyes, we're all done.